COPD Quality Improvement Report: Primary Care
Real Life Practice - Dec. ’19
COPD Quality Improvement Report: Primary Care
1 Your Key Results
14,662 Active Patients
342 (2.3%) COPD Patients
94.2% of active COPD patients have spirometry data to confirm their diagnoses
18.1% of active COPD patients have had a self-management plan in the last year
20.8% of active COPD patients have had two or more exacerbations
38.0% of active COPD patients are listed as current smokers
2 Introduction to the OPC COPD Quality Improvement Review
This report summarises the results of a primary care Chronic Obstructive Pulmonary Disease (COPD) review of your surgery by Optimum Patient Care UK. The review is in line with current NHS Quality Outcome Framework (QOF) standards.
2.1 Purpose
The objective of this clinical audit is to optimise the quality of primary care provision to patients with COPD by:
- Reviewing and improving practices of documentation of the care process in patient electronic medical records.
- Aligning primary care process with the national and international best practice guidelines on COPD management and the COPD cycle of care.
The audit period covers the 12 months prior to the date of the most recent data extraction (Dec. 15 2018 - 2019) and considers:
- COPD diagnosis
- Lung function monitoring
- COPD management and education, including pharmacotherapy
- Markers of COPD control and severity
- Prediction/risk of future exacerbations
- Smoking status
- Comorbidities
- Vaccination Recommendations
2.2 How to Use This Report
This report is designed to provide a simple and clear summary of your current COPD patient management practices, focusing on meaningful indicators and achievable recommendations that are aligned with international guidelines for the management of COPD, and with the NHS NICE and Global initiative for chronic Obstructive Lung Disease (GOLD) recommendations as published in the 2018 NICE guidelines and 2019 GOLD report. Additional rules and recommendations for specific investigated items use resources published by the Medical Research Council (MRC) and the Primary Care Respiratory Society (PCRS). Your successes have been highlighted as well as areas for improvement. The improvement and implementation plan will be discussed with you prior to a re-audit after 3 months.
For all charts in this report, you may hover over the bars to find more information about the total population size, metrics, and/ or counts corresponding to the displayed percentages. The data in the legend of any chart can be excluded from the chart by selecting the series that you would like to remove; likewise, click it again to return it to view. Some charts have a drilldown option that will explore the data in further detail upon clicking on any of the underlined fields.
2.3 Optimum Patient Care UK
Optimum Patient Care (OPC) has been established for over 13 years and continues to support primary care management of chronic diseases in the UK and across the world. Since its conception, OPC UK has continually developed its Clinical Review and Research programs in asthma and COPD, allowing GPs who join the OPC network to further:
- Reflect and add clarity to their data and patterns of care
- Identify those patients with high priority needs & improve patient care
- Compare with other GP’s & national/international guidelines
- Research using a unique data source and contribute to cutting edge science
- Learn with input from world leading experts during local educational workshops
We are committed to bringing research to primary care by advocating for data generated from experience with routine medical care in electronic medical records (e.g., clinical management in primary/ secondary care databases) or national registries (e.g., birth or cancer registries). Ideally, evidence-based good clinical practice relies on a combination of clinical experience (both personal and published real-world data) and experimental (clinical) research implemented. In the UK, OPC has published over 70 papers from the Optimum Patient Care Research Database (OPCRD-UK). We believe that clinical review and research provides an opportunity to deliver evidence-based and data-driven educational programs that make a difference to clinical practice. Our educational programs amalgamate research findings from primary care with clinical practice to provide high quality education.
We would finally like to thank your staff for their help during the review process. We would be happy to discuss the contents of this report with you.
3 Identifying Patients with Active COPD
Interpretation & Recommendations
Your practice has a COPD prevalence (2.3%) that is less than the prevalence that is observed in the OPC Quality Improvement data, which is 3.3% of the 5,752,788 patients.
97 of your patients have factors associated with COPD but have not received an official QOF diagnosis. These are patients who have no asthma, bronchiectasis or cystic fibrosis diagnoses and have met at least one of the following criteria:
- Current or ex-smoker with 3+ cough codes in the last year (12)
- Current or ex-smoker with 2+ lower respiratory infections coded in the last year (23)
- Current or ex-smoker with dyspnoea coded in the last year (64)
- Non-QOF COPD related diagnosis code in the last two years (4)
The number of patients meeting each criteria are displayed in parentheses; kindly note that the counts are not mutually exclusive. It is recommended that these patients are reviewed for a potential COPD diagnosis and treated appropriately for the intitial severity of their COPD.
Possible COPD Breakdown
4 Demographics
4.1 Age Distribution
*Note that patients younger than 35 are excluded from the rest of the review, but are included in the chart above for reference.4.2 Comorbidities
|
Real Life Practice n = 342 |
OPC QI Database n = 187,820 |
|
|---|---|---|
| Asthma | 108 (31.6%) | 41,442 (22.1%) |
| Diabetes | 66 (19.3%) | 32,037 (17.1%) |
| Ischaemic Heart Disease | 65 (19.0%) | 39,891 (21.2%) |
| Heart Failure | 18 (5.3%) | 18,095 (9.6%) |
| Chronic Kidney Disease | 14 (4.1%) | 27,975 (14.9%) |
| Rhinitis | 3 (0.9%) | 1,434 (0.8%) |
| GERDa | 11 (3.2%) | 2,560 (1.4%) |
| Osteoporosis | 44 (12.9%) | 23,417 (12.5%) |
| Depression/Anxietya | 93 (27.2%) | 35,440 (18.9%) |
| Obesityb | 109 (31.9%) | 38,005 (20.2%) |
| Lung Cancer | 7 (2.0%) | 5,721 (3.0%) |
| a Read code entry in last year | ||
| b Read code entry in last year or BMI > 30 in last two years. |
5 COPD Diagnosis
A COPD diagnosis (determined by the presence of a COPD QOF diagnosis code) is confirmed by evaluating a patient’s FEV1 and FVC values. Patients can then be divided into 3 categories:
- Unconfirmed: no spirometry data available
- Unlikely to have COPD: FEV1/FVC > 0.7
- Confirmed COPD: FEV1/FVC ≤ 0.7
5.1 Spirometry Confirmed Diagnosis
Summary Statistics
Patient Breakdown
5.2 COPD Severity
The following severity categories have been adapted from NICE and Global initiative for chronic Obstructive Pulmonary Disease (GOLD) guidelines, published in 2018 and 2014 respectively.
| OPC Report Severity | FEV1 % Predicted | Nice Guidelines | GOLD Guidelines |
|---|---|---|---|
| Mild | \(\small\geq\) 80% | Stage 1 | GOLD 1 |
| Moderate | 50-59% | Stage 2 | GOLD 2 |
| Severe | 30-49% | Stage 3 | GOLD 3 |
| Very Severe | < 30% | Stage 4 | GOLD 4 |
Summary Statistics
*Data displayed only includes patients with a confirmed COPD diagnosis (n = 236).**Please note that total of the percentages displayed may be off by ±1 due to rounding error
Patient Breakdown
6 COPD Health Status
Information from practice recorded data and patient questionnaire responses is used to assess the health status of patients with COPD in three ways:
- The Medical Research Council (MRC) breathlessness score
- COPD Assessment Test (CAT) score
- Combined assessment of COPD using GOLD patient groups
6.1 MRC Breathlessness Scale
| Grade | Degree of Breathlessness Related to Activities |
|---|---|
| MRC 1 | Not troubled by breathlessness except on strenuous exercise |
| MRC 2 | Short of breath when hurrying on level ground or walking up a slight hill |
| MRC 3 | Walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace |
| MRC 4 | Stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground |
| MRC 5 | Too breathless to leave the house or breathless on dressing or undressing |
MRC data is obtained from patient questionnaires when available or from routine practice data.
Summary Statistics
*Note that the name of your practice has been abbreviated to RLP in the above chart for simplicity.
Patient Breakdown
6.2 COPD Assessment Test (CAT)
The COPD Assessment Test provides the following questions and answer choices to patients:
| Your practice has no available questionnaire data to display the CAT assessment score. Please consider sending a COPD Review questionnaire to your patients or including CAT questions in the annual COPD review. |
6.3 GOLD Combined Assessment
The GOLD combined assessment tool divides patients into four distinct groups with the following characteristics:
- Group A: low risk, less symptoms
- Group B: high risk, less symptoms
- Group C: low risk, more symptoms
- Group D: high risk, more symptoms
Patient groups are calculated from MRC or CAT scores, reliever use, and lung function data to provide a more comprehensive measure.
Summary Statistics
Patient Breakdown
7 Risk and Exacerbations
7.1 Future Risk: DOSE Score
Validated research demonstrates that a DOSE Score ≥ 4 is indicative of increased future risk of exacerbation, hospitalization, and mortality. The DOSE Score is calculated by taking the sum of the score for each DOSE category in the table below, ranging from 0 to 8.
| DOSE Item | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| D: Dyspnoea (MRC Score) | MRC 1- 2 | MRC 3 | MRC 4 | MRC 5 |
| O: Obstruction (FEV1% Predicted | \(\small\geq\) 50% | 30 - 49% | < 30% | |
| S: Smoking Status | Non-Smoker | Current Smoker | ||
| E: Exacerbations per year | 0 - 1 | 2 - 3 | > 3 |
Summary Statistics
*Note that the name of your practice has been abbreviated to RLP in the above chart for simplicity.
Patient Breakdown
7.2 Smoking
Smoking status is obtained through patient questionnaires when available or from routine practice data.
Summary Statistics
*Note that the name of your practice has been abbreviated to RLP in the above chart for simplicity.
Patient Breakdown
7.3 Exacerbations
Summary Statistics
*Note that the name of your practice has been abbreviated to RLP in the above chart for simplicity.
Patient Breakdown
8 COPD Management & Review
8.1 Pharmacotherapy
Where asthmatic features/ features suggesting steroid responsiveness in this context include any of the following:
- Any previous secure diagnosis of asthma or atopy
- Higher blood eosinophil count (>300)
- Substantial variation in FEV1 over time (at least 400 ml)
- Substantial diurnal variation in peak expiratory flow (at least 20%)
Below are the percentages of patients on each type of medication therapy for your practice, compared to the OPC QI Database. You can click on any of the bars for your practice to drilldown by COPD severity.
Summary Statistics
Patient Breakdown
8.2 Vaccinations
Please consider providing flu and/ or pneumonia vaccinations as clinically appropriate to reduce the potentially increased risk of exacerbations of their COPD if they contract either illness. It is recommended that all COPD patients receive a flu vaccination annually and a pneumonia vaccination every 5 years.
Summary Statistics
Patient Breakdown
8.3 COPD Reviews
Guidelines suggest that COPD Reviews and Self Management Plans should be advised annually. Read code entry is used to determine the frequency of COPD Reviews and Self-management plans provided in the 12 months prior to this report.
Summary Statistics
Patient Breakdown
9 Recommendations
The practice report recommendations have been grouped into Therapy and COPD Management recommendations. Please consider all groups of recommendations together, as a holistic approach is vital for effective patient care and optimising patient outcomes.
Patients covered within each recommendation can be viewed on your COPD patient level reports, by selecting their name in the Patient Breakdown tab of any section in this report or by navigating to the Patient Reports folder provided with this report. Please refer to the ‘Viewing Patient Reports’ user-guide to assist you in this regard. Alternatively, please contact the OPC service delivery team for assistance. Contact information is located in the bottom left corner of this report.
9.1 Therapy
Recommendations
Explanation & Reasoning
| Recommendations | Explanation & Reasoning |
|---|---|
| Discontinue/ Reduce ICS Therapy | ICS can be safely and effectively discontinued in patients with stable COPD, infrequent exacerbations and no history of asthma or asthma overlap syndrome. Given the increased risk of potentially serious adverse effects and complications, the use of ICS should be limited to the minority of patients in whom the treatment effects outweigh the risks. |
| Optimise Inhaled Therapy | Patients on inhaled steroid in combination with LABA, but with persistent breathlessness and/or exacerbations with FEV1<50%, should have their inhaled steroid dose optimised to improve symptoms and reduce exacerbations. |
| Add LABA or LAMA | A LABA or LAMA should be used in patients who continue to experience exacerbations or persistent breathlessness despite the use of short-acting drugs. |
| Add Mucolytic Therapy | Mucolytic therapy should be considered in patients with chronic productive cough and sputum, who are not currently receiving ICS. Continue use if symptoms improve. Review patient and reassess COPD diagnosis to exclude other underlying causes of chronic productive cough e.g. bronchiectasis, lung cancer, etc. |
| Start Therapy | Patients who do not have a COPD medication on their record but have 3 or more exacerbations documented and/ or a MRC score of 3 or higher should be reviewed to determine if they could benefit from beginning pharmacotherapy. |
| * Adapted from NICE and GOLD guidelines |
Patient Breakdown
9.2 COPD Management
Recommendations
Explanation & Reasoning
| Recommendations | Explanation & Reasoning |
|---|---|
| Provide Smoking Cessation Advice & Support | Smoking cessation is the most effective measure for improving long-term prognosis in COPD. All COPD patients still smoking, regardless of age, should be encouraged to stop and offered help to do so at every opportunity. Smoking adversely affects lung function, need for rescue medications, control with inhaled steroids, and increases exacerbations. Combine pharmacotherapy with appropriate support as part of a programme. Smoking cessation may offer cost savings from reduction in higher dose prescriptions and contribute to achieving QOF targets. |
| Review Inhaler Technique | Incorrect inhaler technique reduces delivery of inhaled drugs to the airways, reduces their therapeutic effects and contributes to inadequate asthma control. Patients should have their inhaler technique reviewed and provided training to use their device adequately. This may offer cost savings from reduction in inappropriate higher dose prescriptions and contribute to achieving QOF targets. |
| Assess Oxygen Saturation | Assess and measure oxygen saturation to identify patients in need of oxygen therapy, especially in patients with severe airflow obstruction (FEV1 ≥ 50% predicted) and to also review patients on oxygen therapy. Please be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression. |
| Refer to Pulmonary Rehabilitation | Offer to all appropriate people with COPD, including those who have had recent hospitalisation for an exacerbation and those who consider themselves functionally disabled by COPD (usually MRC grade ≥ 3). It improves exercise tolerance and symptoms of breathlessness and fatigue. The minimum length of an effective rehabilitation programme is 6 weeks; the longer the programme, the more effective the results/benefits. |
| Screen for Depression & Anxiety | Screen for anxiety and depression using validated tools in people who are hypoxic, severely breathless or have recently been seen or treated at a hospital for an exacerbation. Please keep clinical records of assessments. This is often under-diagnosed and can be associated with poor quality of life and poor prognosis. |
| Provide Weight Loss Advice | Weight loss in overweight and obese patients helps improves symptoms, lung function and medication needs. Please provide appropriate weight loss support and consider referral for dietetic advice. |
| Refer to Specialist | Referral for advice, specialist investigations or treatment may be appropriate at any stage of disease, not just for people who are severely disabled. Patients requiring interventions such as long-term non-invasive ventilation should be reviewed regularly by specialists. |
| Monitor & Provide Osteoporosis Therapy | Patient on corticosteroid therapy are at a slight risk of osteoporosis. Please monitor for osteoporosis and offer prophylaxis. This is often under-diagnosed and can be associated with fractures and poor prognosis. |
| Provide Self Management Plan | Develop an individualised self-management plan in collaboration with the patient and their family members or carers (as appropriate), including educational materials for COPD. Review the plan at future appointments. |
| * Adapted from NICE and GOLD guidelines |
Patient Breakdown
10 References
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2019) https://goldcopd.org/. Accessed July 2nd, 2019.
Medical Research Council (MRC). Dyspnoea/Breathlessness scale https://mrc.ukri.org/research/facilities-and-resources-for-researchers/mrc-scales/mrc-dyspnoea-scale-mrc-breathlessness-scale/. Accessed July 2nd 2019.
National Institute for Health and Care Excellence (NICE). (2018). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. (NICE guideline NG115) https://www.nice.org.uk/guidance/ng115. Accessed July 2nd 2019.
Primary Care Respiratory Society (PCRS). (2012). The Dyspnoea, Obstruction, Smoking Exacerbation Index. https://www.pcrs-uk.org/dose-index Accessed July 2nd , 2019
Jones, P. W., Harding, G., Berry, P., Wiklund, I., Chen, W. H., & Leidy, N. K. (2009). Development and first validation of the COPD Assessment Test. European Respiratory Journal, 34(3), 648-654.
The graphs in this report were produced using the highcharter R package wrapper for the Highcharts Software Library developed by Highsoft. Highsoft software products are not free for commercial and governmental use.